Factors that Health Plans need to consider to improve their Medicare Advantage Ratings

Abhinav Shashank
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Healthcare leaders across the US are of the view that the transition to value-based care should happen, however, not many have the answer to the question of how to do it cost-effectively. Healthcare organizations have to innovate and adapt to the new dynamics or else they might risk their long term viability.

More and more Medicare beneficiaries are opting to enroll in Medicare Advantage plans. Healthcare visionaries who are planning the strategies for the new healthcare scenario are realizing the key to success is focussing on Medicare Advantage.

CMS rates Medicare Advantage plans by assigning them Star ratings that assist beneficiaries in deciding which plan is the most ideal for them. This practice is one of the initiatives of the CMS to ensure long-term success and increased patient satisfaction. As Medicare Advantage is gaining momentum, the only trail of thought would be: What should be done to increase the Star Ratings?

How does CMS assign Star Ratings to MA Plans?

The purpose of providing Star Ratings to MA Plans is to assess the quality of care a health plan offers. There are a total of 45 measures which are categorized under 5 categories. The health plans are assigned Star Ratings on the basis of these measures by determining the quality of care the beneficiaries get.

The more stars a plan gets, the more enrollees are they likely to get. There is a lot to gain by increasing the Star Ratings of a Plan. However, getting Star Ratings in not easy. To get a satisfactory Star Rating, MA Plans have to ensure that the beneficiaries get the best quality of care.

What are the challenges that MA Plans face in improving their Star Ratings?

Most of the measures that determine the Star Ratings of a plan are based on specific service, claims or clinical information that verifies access and delivery of care. For instance, say there were a large number of enrollees who had a chronic disease, the plans can exactly reflect who were the enrollees and what kind of care they received during the year. What MA Plans should do is identify the gaps in care and strategize to deliver better outcomes

However, they usually don’t have access to comprehensive patient data. They mostly end up focussing on just the problems on the broader level and general interventions. They don’t have the resources at their disposal to make specific and targeted interventions. MA Plans in order to really make a difference, need timely and comprehensive information about the enrollees’ health.

Additionally, MA Plans have to ensure that along with high-quality care, they should also have quick access to healthcare as well. To make this happen, they need to focus on efficient collaboration between technology and the clinical staff in their network.

Another factor that affects the Star Ratings is how engaged their members are. For instance, the measures that are associated with patients’ adherence to medication is completely dependent on patient engagement. Patient engagement can ensure that the patients have access to medication and they are taking it on time as prescribed. 

Overall, MA Plans need to create and implement holistic strategies in their network that fulfills all the patient needs.

Social Determinants of Health: How are they important for MA Plans

Non-clinical factors i.e social factors weigh heavily on healthcare outcomes. In fact, they affect the outcomes more than the clinical factors. MA Plans need to focus on extensive, comprehensive patient outreach to determine how many enrollees are susceptible to social factors and what are the social factors they are susceptible to. By doing this, they would be able to provide concentrated assistance to the beneficiaries who need it the most.

MA Plans can use health risk assessments (HRAs) and similar questionnaires to identify their member’s social needs and vulnerabilities. However, the Plans who have used such screening methods have also not been able to cater to their members’ needs because of low completion rates (50% or less). If these questionnaires are administered in person, especially to the at-risk people, it can be useful in factoring social needs for more effective care delivery.

To take this approach to a higher level, MA Plans could combine the social needs with demographic, geographic and claims data to develop predictive models. This model can be then used to stratify the member populations according to risk categories. Application of machine learning algorithms can be used to outreach vulnerable members or refer them to community health workers.

The road ahead

The pace at which Medicare Advantage is progressing is good for the value-based transition initiatives. However, to keep the pace as high as it is, MA Plans need to accommodate measures to factor social determinants of health of the patients along with the clinical improvement initiatives. Addressing the social needs of the patients can boost healthcare outcomes and patient experience and thereby improve the Star Ratings of Ma Plans.

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